CHAPTER 2

HOSPITAL INFECTION CONTROL PROGRAM

AIIMS Hospital has a well-defined infection control policy since 1973.

2.1 INFECTION CONTROL POLICY AT AIIMS
The important components of this policy are:
1. Monitoring of hospital associated infections
Microbiological surveillance.
Investigation and control of outbreaks if any.
Monitoring of anti-microbial resistance.
2. Providing facilities to the hospital staff to maintain good infection control practices.
3. Conducting on going educational/training programmes for all cadres of hospital staff.
4. Making provisions for staff health activities.
5. Having a written document (manual) outlining the various infection control policies and
procedures followed at AIIMS and periodically updating it.
2.2 HOSPITAL INFECTION CONTROL COMMITTEE (HICC):
The policies are implemented under the supervision of HICC the constitution of which is as
follows:
Chairman: Medical Superintendent
Member: Officer in charge Main O.T
One Faculty member each from
Department of Medicine.
Department of Orthopedics.
Department of Anesthesia.
Department of Gastroenterology
Department of Obstetrics & Gynecology
Department of Microbiology
Department of Surgery
Department of Pediatrics
Department of Pediatric surgery
Department of Hospital Administration
Infection Control Nurses
Member Secretary: Faculty member from Hospital Administration

2.2.1 From within the HICC, a core group has been formed on the lines of Infection Control
Team to look after day to day problems. It also implements the educational and training
programmes for the hospital staff.
2.2.2 The Department of Microbiology is responsible for the day to day operations and
monitoring of surveillance activities assisted by the infection control Nurses.
2.2.3 Infection Control Nurses: Four experienced nurses are appointed full time on this
position and their functions are described below.
Functions of Infection Control Nurses
1. Regular visits to all wards and high risk units.
2. Checking nursing supervisors register and records for cases suggestive of infection.
3. Collection of samples from different areas of the hospital for surveillance purpose and
sending them to the lab. The registration form used is different from the routine
investigation forms, so that the culture and sensitivity reports are obtained with minimum
wastage of time.
4. Daily visit to microbiology laboratory to ascertain results of samples collected for
surveillance and to liaise between microbiology and clinical departments.
5. Compilation of ward wise, discipline wise and procedure wise statistics for HAI.
6. Monitoring and supervision of infection among hospital staff.
7. Training of nursing aides and paramedical personnel on correct hygiene practices and
techniques.

CHAPTER 3
SURVEILLANCE OF HAI

Definition Surveillance is the ongoing, systematic collection, analysis, and interpretation of

health data essential to the planning, implementation, and evaluation of public health practice,
closely integrated with the timely dissemination of these data to those who need to know so that
action can be taken in order to reduce morbidity and mortality improve health.
Surveillance - data driven process, Collection, Analysis, Timely dissemination, Implementation,
Evaluation:

Of right data

In the right format

In the right hands

At the right time

At the right place

3.1 BASICS OF SURVEILLANCE

A. Evaluate the population and recognise those at greatest risk for the process of interest or
outcome
1. Healthcare-associated infections (HAI) (outcomes)
2. Patient care practices aimed at preventing HAI (processes)
B. Select the process for surveillance or outcome
Examples of outcomes e.g. Indicators of outcome such as health care associated
infection rates, mortality stratified to severity of illness, device associated infections .Will
inform you about the magnitude of the problems but not the factors contributing to it.
Examples of processes current practice of care delivery e.g. Hand hygiene,
implementation of bundles in device related care, proper isolation precautions .Basically
monitoring of the compliance to evidence based or best practices. It needs resources, so
prioritization is important.
Examples of other events: e.g. Haemodialysis related events,
C. Define observation time period
Plan on the duration for which the data will be collected. Infection control is a continuous
process, ensure monthly capture of the data.
D. Choose an appropriate surveillance methodology
Surveillance Methodology-Routine HAI surveillance in most in-patient healthcare
facilities should be conducted by an infection control professional (ICP) in an active,
patient-based, prospective, priority-directed manner that yields risk-adjusted incidence
rates, as defined below. This methodology will be most useful for the detection of
endemic HAI, rather than for outbreak detection.
E. Monitor for the outcome or process using standardized definitions for all data collected
Standardized definitions are to be adhered to when categorizing an infection as HAI.
Monitoring is essential to identify any breaches in infection control practices as they

effect the patient outcomes In the event of outbreaks and cross transmission additional
data collection, analysis and immediate corrective steps are mandatory
F. Collect appropriate data, if rates are to be calculated
(i.) Numerator data to collect
1. Demographic name, date of birth, gender, hospital identification number, admission date
2. Infection onset date, site of infection, patient care location of HAI onset
3. Risk factors devices, procedures, and other factors associated with HAI
4. Laboratory pathogens, antibiogram, serology, pathology
SOURCES OF NUMERATOR DATA
1. Admission/discharge/transfer records, microbiology laboratory records.
2. Visits to patient wards for observation and discussion with caregivers.
3. Patient charts (paper or computerized) for case confirmation.
a) Laboratory and radiology/imaging results
b) Nursing and physicians notes and consults
c) Admission diagnosis
d) History and physical examination findings
e) Records of diagnostic and surgical interventions
f) Temperature chart
g) Information on administration of antibiotics
(ii) Denominator Data Collection
Remember -Source of numerator data are same as denominator
For device-associated incidence density rates - Device days and patient days are used for
denominators
For SSI rates - Record information on operative procedures selected for surveillance (e.g., type
of procedure, date, any implants placed), detailed logs from the operating room for each
operative procedure
G. Analyse surveillance data always know the units in which you are expressing the indicese.g. device days for device related infections, percentages for HAI and SSI, ratio, for DUR etc.
H. Report and use surveillance information in a timely manner - Right time, Right person
Right data.
3.2 TYPES OF SURVEILLANCE
I. Active and passive
Active -Trained personnel, mainly ICPs, vigorously look for HAI.

Passive -Persons who do not have a primary surveillance role, such as ward nurses or respiratory
therapists, Infectious disease physicians identify and report HAI.
II. Patient-based and laboratory-based
Patient-based -Count HAI, assess risk factors, and monitor patient care procedures and practices
for adherence to infection control principles, requires ward rounds and discussion with
caregivers. Laboratory-based -Detection is based solely on the findings of laboratory studies of
clinical specimens.
III. Prospective and retrospective
Prospective-Monitor patients during their hospitalization.
Retrospective-Identify infections via chart reviews after patient discharge.
IV. Priority-directed and comprehensive
Priority-directed -Focus is on specific events, processes, organisms, and/or patient populations.
Comprehensive -Continuous monitoring of all patients for all events and/or processes.
V. Risk-adjusted rates and crude rates
Risk-adjusted rates-Rates are controlled for variations in the distribution of major risk factors
associated with an events occurrence.
Crude rates -Rates assume equal distribution of risk factors for all events.
VI. Incidence and prevalenceIncidence is the number of new cases in a given time period. Prevalence is the number of cases at
a particular point in time divided by the total population being studied.
HAI INDICES
1. CLBSI (Central line associated Blood stream infection)
2. CAUTI (catheter associated urinary tract Infection)
3. MDROs (Multidrug resistant organisms)
4. SSI rates (surgical site infection)
5. VAP (Ventilator associated Pneumonia)
6. Hand Wash Compliance
7. DUR (Device Utilization ratio)
SURROGATE INDICES OF HAI
1. IV extravasations/ Thrombophlebitis
2. NSI/Sharp injuries Needle stick injuries
3. DAPU (Device associated pressure ulcers)
4. HAPU (Hospital acquired pressure ulcers)

5. How to identify Health care associated infections as per CDC

SECTION
Its best to combine both i.e. lab and ward data hence called Lab based ward surveillance (LBWS)
and selected continuing surveillance which has the best outcome in capturing the authentic data.
Out breaks and cross transmissions can be detected early by this method.
COLLECTION OF DATA AND CALCULATION OF INDICES
1) HAI expressed in percentage
No. of patients with documented HAI in that particular month in that particular area
Total number of admissions in that particular area in that particular month.
This value is multiplied by 100, to give the percentage of HCAI

2) Device Specific Rates

To have uniformity, decide on a particular time of the day when you count the device
days. Suppose you take rounds around 11am, and then ensure that the device days are
counted around that time daily throughout the month. This ensures that there is no
ambiguity in the moving population in ICU (patients shifted for surgery, investigations,
transfers etc.)
a) Catheter associated Urinary tract infection (CAUTI)
b) Central line associated Blood stream infections (CLBSI/CLABSI)
c) Ventilator associated pneumonia (VAP)
d) Device utilization ratio (DUR)
e) BSI Rate associated with Haemodialysis
The device associated infections are expressed in Device Days (DD)
Determine number of device-days used as denominator:
Device-days = total number of days of exposure to device (ventilator, central line, or urinary
catheter) by all patients in selected population during selected time period.
E.g.-In an NICU there are 7 patients on say Ventilator on day one, 8 patients on day two , 5
patients on day three and so on

Add 7+8+5+ and so.on till the end of the month. The sum of the days would become
Ventilator days for that month. It is similarly calculated for other infections.
Once the denominator of device days are known, device related infection rates can be calculated.
Patient days= total number of days that patients are in the ICU during selected time period e.g.
In an NICU there are 10 patients on day one, 14 patients on day two,12 patients on day three, and
so on. Add these and the total number at the end of one month is your patient days.

a) CLABSI= No. of CLBSI in that particular ICU X

1000

Central Line days

b) CAUTI = No. of CAUTI in that particular ICU X

1000

Urinary catheter days

c) VAP = No. of VAP in that particular ICU X 1000
Ventilator days
d) Device utilization ratio = Device - days
Patient days
e) BSI Rate associated with Hemodialysis
DUR indicates the magnitude of devices used.
The DUR can range between 0 and 1.
DUR of 0 - zero devices per patient on an average day (best scenario)
DUR of 1 every patient had a device on an average day (worst scenario)
Example: NICU
For the past month, a neonatal ICU had 180 central line days and 225 patient-days:
DUR = 180 central line days = 0.80
225 Patient days
Conclusion: 80% of patient days were also central line days over the last month. Eight out of 10
NICU patients had a central line in place on an average day last month.
The denominator is simply calculated by counting the number of patients being haemodialysed
each month and adding them together.
For example, if there were 45 patients in January, 40 in February and 50 in March, the
denominator would be (45+40+50=135) 135 dialysis patient months for the 3 month surveillance
period.

IMPLEMENTABLE TIPS:
A) Hospital Surveillance Plan
Need to have a good network of motivated staff, clear case definition, prior training in order to
collect authentic data.
1) Select a specific parameter (e.g. CLBSI) in a specific location (e.g. MICU) and define a time
period (one month-June2014).
2) Draw out details of the form which will capture the details (demographics, site, and dates of
insertion)
3) Select and have a pre meeting with the data collectors.
4) Intimate the healthcare staff where the information will be collected.
5) Share the data with all concerned in record time.
B) Surveillance method
1) Data collectors must interact with the doctor /sister at site.
2) Fill out details in the form from patient records, on site examination, lab confirmation.
C) Data analysis and interpretation
1) Collect the filled out forms, analyse and interpret the data.
2) Write out the best solutions to the problems foreseen in the data.
D) Data sharing Shared with stake holders-Members of IPCC, Nursing in-charges can have
some selective data pertaining to their department. Always ensure confidentiality and assure
them that these data is to introspect and have a zero tolerance to infections attitude. Ensure that
no department is penalized because of the gaps in practices of infection control.

CHAPTER 5
STERILISATION, DISINFECTION & DECONTAMINATION PRACTICES
Decontamination encompasses cleaning, disinfecting and sterilizing (See Glossary).
It is required in the following situations:
Before use of a contaminated equipment/device for any patient.
Before sending contaminated equipment for further processing in the CSSD
Before sending used &contaminated needles and syringes for disposal.

For the inanimate environment which is likely to be infected and could be a potential

source of HAI.
Before any item is subjected to disinfected /sterilization thorough cleaning is mandatory
to remove organic material that may interfere with these processes.

The most common factors associated with transmission of infection:

1) Inadequate manual cleaning

2) Inadequate exposure of surfaces to the disinfectant.

3) Inadequate rinsing and drying.
4) The use of automated endoscope re-processors.
5.1 INFECTION RISK TO PATIENTS FROM EQUIPMENT, MATERIALS AND THE
ENVIRONMENT
The choice of the decontamination method would be determined by the infection risk to the patient.

Critical medical and surgical devices and instruments (e.g. devices and surgical
instruments) that enter normally sterile tissue or the vascular system or through which a

sterile body fluid flows, are to be sterilized before being used on any patient.
Semi critical patient care equipment that comes in contact with mucous membrane
(e.g. gastroenterological endoscopes, endotracheal tubes, anesthesia breathing circuits

and respiratory therapy equipment) or non-intact skin requires a high level disinfection.
Non critical patient care surfaces (e.g. bedrails, over bed table etc.) and equipment that
touch intact skin (e.g. blood pressure cuffs) require low level disinfection.

5.2 TYPES OF DISINFECTIONS

I. High level disinfectants: 2% glutaraldehyde, stabilized Hydrogen peroxide and 1%sodium

hypochlorite solution (10,000ppm of cl2) will destroy all microorganisms including vegetative
bacteria, most bacterial spores, fungi, viruses including enteroviruses and Mycobacterium
tuberculosis, except some bacterial spores.
II. Intermediate level disinfectants: 0.1%sodium hypochlorite solution (10,00ppm of cl2),ethyl

or isopropyl alcohol (70%) iodophores and phenolic solution will destroy vegetative bacteria
Mycobacterium tuberculosis, most viruses and fungi but not bacterial spores.
III. Low level disinfectants: quarterly ammonium compounds e.g. Benzylkonium chloride,

destroy most vegetative bacteria, fungi and enveloped virus e.g. HIV, but they will not kill
bacterial spores, Mycobacteria and non-enveloped virus like entroviruses.

5.3 METHODS OF STERILISATION

It is the process of destroying all micro organisms including spores.

Steam is the preferred method of sterilizing critical medical and surgical instruments that

are not damaged by heat, steam, pressure and moisture.

Some items can be sterilized by dry heat.
Low temperature sterilizations technologies e.g. Ethylene oxide (ETO) are used for
reprocessing critical care patient equipment which are heat sensitive.

5.3.1

Packaging

Packaging is done to provide a barrier to microorganisms and moisture.

It should be sufficiently strong to withstand punctures and tears.
Packaging material should be compatible with the sterilization process.

5.3.2

Monitoring

Mechanical, chemical and biological monitors can be used to evaluate the effectiveness

of the sterilization process.

Each load is monitored with mechanical (time, temperature, pressure) and chemical

(internal and external) indicators.

Biological indicators (spores) should be used weekly to monitor the effectiveness of

sterilization.
Whenever mechanical and chemical indicators show inadequate processing the loads

should be reprocessed.
Chemical indicators as strips should be used with every pack.

4.3.3 Load Configuration

The items are loosely placed so as not impede the flow of steam through and in between
the packs in the autoclaves.

4.3.4 Storage of Sterile Items

The sterile storage area should provide protection against dust, moisture insects,

temperature and humidity.

The sterilized items are labeled clearly with the date and contents of the pack.
Whenever the integrity of the pack is suspect it should be re-sterilised.
Unused and /or unopened items should be re-sterilised after every 72hours.

5.4 CENTRAL STERILE SERVICE DEPARTMENT (CSSD)

The CSSD at AIIMS is located behind the casualty. It functions round the clock in three shifts
and is operationally supervised by an ANS (HR).
At present there are two big (96cu ft) and seven small (36cu ft), autoclaves are installed at CSSD
which cater to the requirements of the entire institute. These autoclave operate a temperature of
121c, at a pressure of 15 psi for a duration of 30minutes.
The autoclaving cycle is computerized and changes of pressure and temperature are recorded on
a paper disc. Monitoring is also done by strips of heat sensitive tape which are applied externally
and internally. Once a week, 4, 5 packs containing Bacillus sterothermophilus spores are
autoclaved keeping them in the most unreachable part of the autoclave chamber, these are then
cultured to see whether the spores have all been destroyed.
The entire cycle of autoclaving from loading of unsterile packs to unloading of sterile packs
takes nearly 3hours.
There are physically demarcated areas for reception, cleaning and washing, packing processing,
storage and distribution within the CSSD. The method of supply is exchange of clean for dirty
sets. The sterile sets stocked in the CSSD store for a maximum period of 72hours after which
they are re-autoclaved if they are still unused.
5.4

PERIPHERAL STERILISTION FACILITIES

Besides this central facility we have peripherally distributed equipment to ensure the availability
of sterile instructions at all times.
The main OT complex on the eighth floor is provided with a flash sterilizer. This is a modified
autoclave in which steam sterilization takes place at a much higher temperature (170c) and
pressure (20psi), consequently the time is reduced to about 5 minutes.

The Main OT, Orthopedic OT, Neurosurgery OT, CTVS OT, Cath lab and RPC

OT

are

provided with Ethylene oxide sterilizers (ETO). These are used for sterilizing temperature and
moisture sensitive medical devices and supplies for e.g. fibre optic scopes ventilator tubings and
vascular catheters, etc.
4.6 LAUNDRY SERVICES
The laundry at AIIMS is also a central facility where combined washing of linen from the main
hospital, CNC, RPC, and IRCH is done. Disinfection of soiled linen is achieved by chemical and
thermal methods. The soiled linen is first sluiced and then treated 1%bleach. Then the linen is
washed in mechanized washing machine through which steam is bubbled heating the water to
70c for sterilization.
4.7 DIETARY SERVICES
In the central kitchen facility due precautions are taken to ensure proper hygiene and cleanliness
in cooking, serving and transportation of food. The mainstay is preventing spread of diseases
with an oro-fecal mode of transmission is the proper washing of hands as highlighted in the
chapter on aseptic practices. The dietetics department uses the glucose bottles for dispensing
different in-house prepared feeds. These bottles should be boiled and dried before use. The
feed should be prepared in the laminar flow cabinet under all aseptic precautions and should be
appropriately stored.
4.8 RECOMMENDATIONS FOR STERILISATION AND DISINFECTION
For reprocessing of various equipment manufacturers recommendations should be followed.
An effort should be made to procure items that are heat and moisture resistant.
Table ________ lists the recommended reprocessing of commonly used equipment in hospitals. Details
of disinfections and sterilization of some commonly used items are given below:
1. Airways and endotracheal tubes: Autoclave or chemically disinfect. As far as possible use
disposables.
2. Ampoules: the neck should be wiped with 70%alcohol before cutting it.
3. Cheattle forceps: clean with soap, dry, autoclave and store dry. Keep in a dry sterile bottle or
container. It should be replaced every 12hours or earlier if it is visibly contaminated.

4. Flexible endoscope: all the channels should be flushed and brushed, if accessible, to remove all
organic residue. Clean the external surfaces and accessories of devices by using a soft cloth, sponge or a
brush. After high level disinfection all channels must be rinsed with sterile water followed by a rinse with
70% alcohol. Then the channel should be forced air dried. The endoscope should be hung in vertical
positions (manufacturers instructions should be followed stringently).
5. Rigid endoscopes, for example bronchoscopes, arthroscopes, cystoscopes and laproscope: As these
instruments pass through normally sterile tissues they must be subjected to sterilization. It this is not
possible then high level flexible endoscopes (manufactures instruction should be followed stringently)
6. Incubators: (neonates): should be washed with detergent and dried with sterile wipes. For terminal
disinfection fumigation with formaldehyde is performed.
7. Instruments: Contaminated surgical instruments must be washed in a hot water washer disinfector
before sterilization. Heat sensitive instruments should be cleaned with chlorine releasing chemical, 2%
glutaraldehyde or 70% alcohol.
8. Sputum containers: As far as possible use disposable containers. If these are non-disposable, they
should be emptied and cleaned with care and heat disinfected.
9. Oral thermometers (mercury and glass): preferably use individual thermometers, wipe with
70%alcohol and store dry. For common use thermometers wipe and dip in 70%alcohol and store dry.
10. Stethoscope: Wipe with 70%alcohol once daily or when visibly soiled. In critical areas dedicated
instruments should be used for each patient. This is not possible then cleans with 70%alcohol after each
use.
11. BP Cuffs: In critical areas BP cuffs with synthetic covers should be cleaned by 70%isopropyle
alcohol in between patients. In critical areas dedicated instruments should be used. Cuffs with cloth
covers should be washed periodically or when visibly soiled.
12. Laryngoscope (blade): After each use clean with detergent and water to remove any organic material.
Disinfect with 70%isopropyle alcohol swab and store dry. (Handle: clean with a wet cloth and store in dry
linen.
13. Suction equipment:
* Equipment: Clean regularly with a wet mop.
* Bottles: empty regularly.

Wash with detergents and hot water and store

dry.

* Tubings: Preferably use autoclavable tubings. Disinfect/sterilize tubings every 24 hours. Wash tubings
with detergent and water, rinse and remove extra water. Disinfect using 2%glutaraldehyde. The tubings
must be submerged and the lumen should be 20-30 minutes. Remove from the bucket and rinse with
sterile water and dry. Store in dry linen, if extension tubing is cleaned and decontaminated with
glutaraldehyde or sterilized with ETO.

14. Anaesthesia circuits and ventilators (including humidifiers, T-piece etc.).

Clean the tubings with detergent and water to remove organic material and rinse with water. Then
submerge the tubings in a container /bucket with 2%glutaraldehyde. The lumen of tubings should be filled
with the disinfectant and the duration of contact should be at least 30 minutes, for sterilization immerse
for 8-10hours. Remove from bucket, rinse with sterile water and dry. Store in sterile linen (follow
manufacturers recommendations).
15. Nebuliser: Preferably single set should be used for individual patients and the set should be
disinfected daily using the same procedure as that for ventilator circuits. Ensure that the chambers and
tubings are absolutely dry.
16. Facemask, ambu bags and reservoirs: These should be disinfected after each use using same
method as for ventilator circuits.
17. O2 hood: Wash with soap and water, store dry.
18. Needle and syringes: Preferably use only disposable.
19. Body piercing needles and neurologic test needles: Ideally disposable single use items should be
used. However , in certain exigencies, if they have to be reused these should be sterilized with either
ethylene oxide after proper cleaning to remove organic material or 2%gultaraldehyde with a contact
period of 8-10 hours, if they are heat stable then they can be autoclaved.
20. Probes of pulse oximeter and temperature probes: Should be cleaned if visibly soiled and
disinfected with 70% isopropyl alcohol.
21. Wall humidifiers and O2 tubings: Should be decontaminated and disinfected every 24hours and
stored dry.
Discard of Blood bags:
Blood products need to be safely treated and disposed of in an environmentally friendly way. Steam
sterilization (autoclave) should be the preferred option (+121C for 20 minutes). When incineration
remains the only option, then high temperature pyrolitic incinerators (>1200C) would be appropriate.
Blood transfusion bags contain above 50% of polyvinyl chlorine (PVC) and their incineration at low
temperatures generates products of incomplete combustion such as dioxins or furans. The management of
waste must be carried out professionally as part of the quality management of the blood transfusion
programme. Disposal via the laboratory sink or underground drains is strongly discouraged without prior
disinfection with a chlorine-based solution and neutralization of potentially infected effluents into a buffer
tank. In any case the blood establishment drainage system should be connected to the sewerage or to a
soakaway pit, taking into consideration that a minimum distance of 30m must be respected with existing

water sources. (Reference: World Health Organization. Manual on the management, maintenance
and use of blood cold chain equipment, 2005)
Terminal Disinfection of an Area:
A terminal clean is defined as a procedure required to ensure that an area has been
cleaned/decontaminated following discharge of a patient with an infection (i.e. alert organism or
communicable disease) in order to ensure a safe environment for the next patient. Terminal cleaning
should be carried out after a patient with an alert organism or communicable disease has been discharged
(or transferred), in order to ensure a safe environment for the next patient. Bed screens, curtains and
bedding should be removed prior to the room/area being decontaminated.
When the environment is potentially contaminated, disinfectants such as sodium hypochlorite must be
used. For disinfectants to work effectively, the surface being decontaminated must be free from organic
soil. A neutral detergent solution should be used to clean the environment prior to disinfection or a
combined detergent /disinfectant may be used.
There is substantial evidence to support the effectiveness of hypochlorite solutions (1000ppm) and
sodium dichloroisocynaurate (NaDCC) for the disinfection of surfaces contaminated with norovirus or C.
difficile. The effectiveness of disinfectants as part of control measures during outbreaks of other
pathogens has also been widely reported.
(Neutral detergent followed by a disinfectant containing 1000 parts per million (ppm) available chlorine
(av cl) (or a combined detergent/disinfectant (1000ppm av cl)) should be used for decontamination of the
isolation room/cohort area)
Environmental Fogging Clarification Statement
CDC and HICPAC have recommendations in both 2003 Guidelines for Environmental Infection Control
in Health-Care Facilities and the 2008 Guideline for Disinfection and Sterilization in Healthcare Facilities
that state that the CDC does not support disinfectant fogging. Specifically, the 2003 and 2008 Guidelines
state:
2003: Do not perform disinfectant fogging for routine purposes in patient-care areas. Category IB 2008:
Do not perform disinfectant fogging in patient-care areas. Category II
These recommendations refer to the spraying or fogging of chemicals (e.g., formaldehyde, phenol-based
agents, or quaternary ammonium compounds) as a way to decontaminate environmental surfaces or
disinfect the air in patient rooms.
These recommendations do not apply to newer technologies involving fogging for room decontamination
(e.g., ozone mists, vaporized hydrogen peroxide) that have become available since the 2003 and 2008

recommendations were made. These newer technologies were assessed by CDC and HICPAC in the 2011
Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings,
which makes the recommendation:
More research is required to clarify the effectiveness and reliability of fogging, UV irradiation, and
ozone mists to reduce norovirus environmental contamination. (No recommendation/unresolved issue)
The 2003 and 2008 recommendations still apply; however, CDC does not yet make a recommendation
regarding these newer technologies. This issue will be revisited as additional evidence becomes available.
Fogging may be done in the following situations:
1. Commissioning of new critical areas such as OTs and ICUs.
2. After annual maintenance in the above mentioned areas.
3. Fogging of OTs may be done on the basis of any microbiology surveillance reports and/or clinical
procedures carried out in the operating areas. No routine fogging is recommended.
4. Any civil or engineering works should invite fogging of OTs.
One demonstrated use for this technology is to assist with control of an outbreak caused by
microorganism(s) which is continuing unabated, wherein the environment of care is implicated. Other
possible applications would be for rooms previously occupied by patients on Contact Precautions (CP) for
multidrug-resistant organisms (MDRO) or CDI, or to decontaminate whole areas or patient care
equipment that epidemiologic investigation implicates possible involvement in clusters of HAIs.
Scientific studies do show HP vapor or mist is effective for patient room non-porous surfaces, including
hard surface equipment for a wide range of MDROs such as MRSA, VRE, gram negatives such as
Acinetobacter and Serratia spp., viruses (e.g., rotavirus; norovirus), fungi, B. anthracis, protozoa but
most importantly, C difficile spores. Other potential areas include: sensitive equipment that may be
difficult to disinfect after cleaning; quarantine rooms in ED (for patients with suspected or proven
infectious agents); animal lab facilities.
Table: Disinfection/sterilization of Instruments and Equipment
Sl.
No.

Items to be disinfected

Schedule for
disinfection

1.

Resuscitation equipment
(Laryngoscope blade,
AMBU bag, mask, E.T.
stylet)

1. After each use

2. If not used for any
patient in 24 hours
time, equipment
should be

Procedure for
disinfection/sterility
maintenance
1. Clean with water and soap
solution (detergent) to remove
bioload.
2. Dry and then disinfect with
Bacillol25 or Spirit.

Alert/Remarks

disinfected every
day before 10 am
Ambu Bag and
accessories

1. After each use

2. If not used for any
patient in 24 hours
time, equipment
should be
disinfected every
day before 10 am

2.

Cheatle forceps

3.

Thermometers

4.

O2 humidifier

1. Once in 24 hours
every day before 10
a.m.
2. Whenever
contaminated.
3. In OT every
nursing shift.
1. After each use.
2. Set up thermometer
tray once in 24 hours
before 10 a.m. even if
unused.
1. Once in 24 hours,
every day before 10
a.m. whether being
used or not.
2. After patient
discharge/shift/death.

5.

O2 /Suction tubings

1. After each patient

use.
2. Once in 24 hours.
3. Whether being used
or not in 24 hours, it
must be disinfected.

3. Store L.scope blade and E.T.

stylet in sterile pad.
1. Wash with water and
detergent (ambu bag, AR
valve and other
accessories) to
decontaminate and then
immerse them in high level
disinfectant solution for 30
Mins
2. After disinfection time
ambu bag and other
accessories should be
thoroughly rinsed with
sterile water.
3. Dry and store in a sterile
wrapper
1. Clean with water &
detergent
2. Disinfect by autoclaving
3. Store dry in a sterile bottle
with sterile cotton.
1. Clean with water and
disinfect with spirit.
2. Store dry either in sterile
bottle or thermometer
containers.
1. Wash with water and
detergent
2. Disinfect by submerging in
Korsolex/Cidex solution for 30
minutes.
3. Then rinse preferably with
sterile water.
4. Dry in a clean area and store
in sterile drapes/bags.
5. Use only sterile water for
humidification.
6. Fill the water up to the
designated level.
1. Wash with water and
detergent
2. Disinfect by submerging in
Korsolex/Cidex solution for 30
minutes.
3. Ensure disinfectant solution

Label the bottle

with date and time.

- If water level falls

below the
designated mark.
- empty the water.
- Refill with fresh
sterile water.
-DO NOT TOP UP
-Always use freshly
opened sterile
water bottle.

- If patient is on O2
for more than 24
hours, tubing needs
to be changed.

6.

Nebulizer
tubings/cup/chamber

1. Disinfect nebulizer
tubing in every nursing
shift.
2. Disinfect nebulizer
cup after each patient
use.
3. Nebulizer chamberonce in 24 hours before
10 a.m.

7.

Ventilator
circuits/humidifier

1. After each patient

use/discharge/ death.
2. If visibly soiled or
mechanically
malfunctioning.
3. Every 72 hours (3
days) whether being
used or not.

8.

Sterile steel drums/sterile

sets

1. Shelf life 72 hours.

2. Every 72 hours (3
days) whether being
used partially or
unused.

enters the tube lumen.

4. Then rinse, preferably with
sterile water, dry the tubes by
hanging in a clean area.
5. Use fresh tubings for each
patient.
1. Wash with water and
detergent
2. Disinfect by submerging in
Korsolex/Cidex solution for 30
minutes.
3. Ensure disinfectant solution
enters the tube lumen.
4. Then rinse preferably with
sterile water, dry the tubes by
hanging in a clean area.
5. Use fresh nebulizer cup for
each patient.
6. Disinfect used nebulizer
cup.
1. Wash with water and
detergent
2. Disinfect by submerging in
Korsolex/Cidex solution for 30
minutes.
3. Ensure disinfectant solution
enters the tube lumen.
4. Then rinse preferably with
sterile water, dry the tubes by
hanging in a clean area.
5. If ETO facilities available
it can be sterilized by ETO
machine.
6. Circuits which can
withstand autoclaving, can be
sent for autoclaving.
7. Use sterile water for
humidification and fill up to
the mark.
1. Clean the instruments with
water and detergents.
2. Dry them in a clean area.
3. Then pack the sets and send
for autoclaving.
4. Store autoclaved sets in a
clean area.
5. Ensure sterile steel drums
are stored with their lids and
steam inlets closed.

Use fresh cup and

mask for each
patient.

- If water level falls

below the mark in
humidifier bottle,
empty then refill
with fresh sterile
water.
- DO NOT TOP
UP.

- Whenever the
integrity of the
pack is suspected, it
should be resterilized.
- Storage area
should protect
against dust,
moisture, insects,
temperature and
humidity.

9.

Small steel trays used for

injections to carry

1. Every 24 hours, if
unused.
2. Disinfect after each
schedule of injections.
3. If visibly soiled

10.

Needle destroyer
Puncture proof containers
with boilable hazard

1. Visibly soiled.
2. Every day before 10
a.m. (24 hours)

11.

Cleaning of surface
areas : General wards,
nursing counter,
treatment room, POP
cubicles,
ICUs/HDUs/OTs walls,
all counters, bed rails,
lockers, over head table,
equipments, door knobs
etc.

1. Every day before

10 a.m.
2. If found visibly
soiled

1. Wash with water and

detergent.
2. Disinfect by submerging in
Korsolex/Cidex solution for 30
minutes.
3. Then rinse with sterile water
and dry.
4. Separate steel tray for
individual patients in ICUs
Puncture proof containers :1. Do not hold the mutilated
needle in puncture proof
container more than 24 hours.
2. Change every 24 hours.

1. Wet mop with surface

disinfectant (bacillocid,
carbolic acid)

- Check daily if the

needle destroyer is
in working
condition.
- Make sure the
puncture proof
container has biohazard label.
- Always use
freshly prepared
solution and
required amount.
- Discard the
solution after use.

Sl.
No.
1.

2.
3.

4.

5.

6.

7.

Preparation of disinfectants/solutions:
1. Disinfectant solutions should be re-constituted and changed according to in use life span As
per manufacturers recommendations.
2. Label the container with name of the solution/date/time of preparation/date of expiry.
3. Always use PPE while handling the chemicals (gloves, mask, apron).
4. Opened Normal saline bottles (for dressing) should not be used beyond 24 hours. Replace
fresh bottles every day morning before 10 a.m. Label the bottle with date/time.
Name of the
Avail.
Req.
Method of dilution
Contact
Maximu
Remarks
disinfectant
Conc.
Conc.
time for
m in use
solution
disinfection span**
Glutaraldehyde
2%
2%
Add activator
20-30
14 days
2.45%
2.45%
powder/liquid to the 5
minutes
28 days
ltr. Solution and use
undiluted
Korsolex Rapid
Pure
5%
5ml Korsolex Rapid +
5minutes
7 Days
95ml water
Bacillocid :
Pure
2%
20 ml Bacillocid + 980
Quick
Do not mix
(Benzylkonium
ml water
disinfection
with other
chloride,
0.5%
5 ml Bacillocid + 995
of surface
cleansing
Glutaraldehyde
ml water
areas
agents
with chemically
bound
formaldehyde)
Chlorhexidine
Pure
3.5%
500 ml solution (17.5
24 hours
Use only
Gluconate and
ml pure savlon + 482.5
for skin
Cetrimide
ml saline/boiled water)
disinfection
solution (Savlon)
Phenol (carbolic
100%
5%
Warm the phenol bottle
10-15
24 hours
Use freshly
acid)
(crystal
in hot water basin to
minutes
prepared
form)
make it into liquid form.
solution
5 ml phenol + 95 ml
water
Sodium
10% + 1 1%
10 ml sodium
20-30
8 hours
DO NOT
Hypochlorite
hypochlorite solution +
minutes
USE
Solution
5% + 1
1%
90 ml water
reconstitute
20 ml hypochlorite
d solution
solution + 80 ml water
beyond 8
hours
Baccishield
Pure
10% for
100ml of Baccishield in
Always use
disinfection 900 ml of water for 10%
freshly
of items/
prepared
equipments 200ml of Baccishiled in Fogging time
solution
surface.
800 ml of water for 20% 1 hour:
(half an Hour
20% for
for running
fogging
the machine
and half an

hour keep
the door
closed)
8.

Bacillol Spray

Use as available

Do not use
it as surface
cleaner

** May need to replace earlier if solution is visibly contaminated or on basis of in-use test report.

Reuse of a Single Use Devise (SUD)

These are critical items and should be sterilized.
Gluteraldehyde is not recommended for such situation e.g. biopsy needles commonly reused for poor patients should undergo autoclaving or plasma sterilization.
The patient must be informed about the re-use of a SUD.

CHAPTER 7
INFECTION CONTROL IN LAUNDRY AND LINEN SERVICES

INTRODUCTION
Linen in the hospital setting is an important marker of quality of services in that hospital. Most of
the quality assessment of services of a health facility from a patients perspective comes from his
experience with food, linen and washrooms of the hospital. Careful and safe laundering of the
hospital linen therefore becomes an important responsibility of the hospital manager. Evidences
of recent times have suggested hospital linen could be an important source of infection when not
maintained properly.
Reports have suggested the presence of a number of micro-organisms in hospital linen at various
places including moulds, Staphylococcal species, Corynebacterium spp, MRSA, C. difficile,
gram negative bacilli, Micrococcus and Enterococcus species, Rota viral RNA, Parainfluenza
virus and many others. Risk may be both to the patient as well as the employee of the hospital.

INFECTION CONTROL IN LAUNDRY AND LINEN SERVICES

Hospital linen may be of various categories such as bed linen, garments, OT linen or staff
uniform which undergo processing at various levels. Most infection control measures need to be
targeted in the following steps of laundering:

Collection
and sorting
of used
linen

Internal
transportati
on of used
linen

Processing
of linen at
laundry

Packaging
and
distribution
of clean
linen

Storage of
clean linen

Measures of infection prevention therefore need to be targeted towards the following steps of
processing linen.
PROCESS
Collection
and
sorting of used
linen

INFECTION CONTROL MEASURES

o The place for sorting of used linen should be away from any patient
care area.
o The space should be well lighted and ventilated.
o Soiled linen should be handled as little as possible
o Appropriate personal protective measures should be adopted by the
person handling used linen
o Sorting should be performed carefully to prevent any needle stick
injury as often soiled drapes, etc. may contain sharps.
o Count of the different types of linen should be maintained during
sorting so that there is no need for handling the same for counting
again.
o Provision should be made to store the heavily soiled linen separately
from those that are not heavily soiled.
o Use of color coded laundry bins for the same may be used of fixed
structures as already exists in some of the wards.
o Collection of used linen should be done at such times so as to avoid
public rush hours.

Internal
transportation of
used linen

o Appropriate personal protective equipment may be used by the

hospital worker involved in transportation of the used linen.
o An adequate sized laundry trolley should be available for the same.
o There should be no over loading of carts/ trolleys with used or
soiled linen. While transportation of the same they may be
adequately covered using clean/used linen, however it should not be
soiled one.
o The person carrying these used linen in the trolleys should used an
earmarked passage for the same preferably low traffic areas of the
hospital.

o In case they need to use the corridors or routes with higher traffic,
they should announce aloud so that people may move aside to give
way for these trolleys
o Speed of pulling the trolleys should be controlled so that they do not
bang or touch the side walls or any other structure of the hospital.
Processing of the
linen at laundry

o When used linen is brought to the area of laundering, they should be

received from a route that is not used for carrying clean linen.
o All linen items should be thoroughly washed before reuse.
o Decontamination of linen prior to washing is not necessary except
for heavily soiled linen otherwise the fabric deteriorates early.
o Appropriate personal protective measures should be adopted by
workers during washing and drying also (such as plastic/ rubber
apron)
o Soiled linen should be washed separately from non soiled linen.
o Those heavily soiled may be pre-soaked in soap, water and bleach.
o Washing linen at 70-80 degree C for over 20 minutes with a
detergent is an effective method to clean and reduce bacterial count.
o Washing may be repeated if linen appears unclean.
o Clean linen should be completely dried after washing.
o After total drying they should be checked for holes, thread bare
areas and repaired accordingly.
o Clean and dry linen should be calendared as required and packed for
distribution.
o Linen likely to go for sterilization need not be calendared as steam
penetrability is reduced after ironing linen.

Packaging and Storing Clean Linen

distribution
of
o Keep clean linen in clean, closed storage areas.
clean linen
o Wash hands before handling clean linen.
o Use physical barriers to separate folding and storage rooms from
soiled areas.
o Keep shelves clean.
o Handle stored linen as little as possible.
Transporting and Distribution of Clean Linen
o Clean and soiled linen should be transported in separate
carts/trolleys.
o They should be labeled to avoid confusion.

o Carts or trolleys should be washed according to schedule.

o Clean linen must be wrapped or covered when transporting to avoid
contamination
Storage of clean
linen

o
o
o
o
o

Protect clean linen until it is distributed for use.

Do not leave extra linen in patients rooms.
Handle clean linen as little as possible.
Avoid shaking clean linen. It releases dust and lint into the room.
Clean soiled mattresses before putting clean linen on them

RECOMMENDED PPE FOR PERSONNEL PROCESSING LINEN

1. Gloves (preferably household utility gloves) and closed shoes that protect feet from
dropped items (sharps) and spilled blood and body fluids, should be used when:
Handling disinfectant solutions
Collecting and handling soiled linen
Transporting soiled linen
Sorting soiled linen
Hand washing soiled linen
Loading automatic washers
2. Plastic or rubber apron and protective eyewear should be worn when
Sorting soiled linen
Hand washing soiled linen
Loading automatic washers
INFECTION PREVENTION MEASURES FOR LAUNDRY WORKERS:
1. Use of personal protective equipment such as gloves, plastic/rubber aprons, gowns,
facemask and gum boots should be practiced as a protocol.
2. Workers should be immunized against tetanus and Hepatitis B which are possible in
Indian context.
3. Protocol should be established for workup and treatment of workers sustaining needle
stick injury while processing linen.
4. Regular training and instructions to the workers regarding safe handling of linen.
QUALITY CHECK ON LAUNDERING PROCESS AT AIIMS
The HIC lab in the Department of Microbiology has standardized the following SOP for
bacteriological quality of laundered linen or dry cleaned blankets at AIIMS hospital which
will be used for random checks of quality of laundry processes.
After the fabric is received:

1.
2.
3.
4.
5.

Under sterile conditions, cutout 10 cm X 10 cm area of a laundered /dry-cleaned fabric.

With the sterile forceps place it on sterile culture plate for 15-20 minutes.
Remove the cloth sterile forceps and transport plate to the Microbiology lab.
The plate is to the incubated at 370C for 24 hrs. And observed for bacterial growth.
If the numbers at colonies are 20 it will be considered unsatisfactory process.

OTHER IMPORTANT MEASURES:

1. Laundry floors and work areas should have a regular cleaning schedule using an EPA
registered disinfectant.
2. Areas should be vacuumed to remove lint
3. Wet-vacuumed pick-ups should be used for terminal cleaning.
4. Casual visitors should not be allowed inside the laundry.

CHAPTER 10
BIOMEDICAL WASTE MANAGEMENT AT AIIMS

Appropriate management and disposal of hospital waste is one of the mainstays of hospital
acquired infection. The Biomedical waste management policy followed at AIIMS is as per the
Biomedical Waste Management Rules 2016, notified by the Ministry of Environment, Forest and
Climate Change, Government of India.
CATEGORIZATION OF BMW

The following table enlists the various categories of biomedical waste along with their collection,
segregation, treatment and disposal.
Category

Type Of Waste

Yellow

(a) Human Anatomical

Waste:
Human tissues, organs, body
parts and fetus below the
viability period (as per the
Medical
Termination
of
Pregnancy Act 1971, amended
from time to time).
(b)Animal Anatomical

Type Of Bag Or
Container For
Collection
Yellow colored
non-chlorinated
plastic bags

Treatment
Option

And

Incineration or Plasma
Pyrolysis or deep
burial*

Disposal

Waste :
Experimental animal carcasses,
body parts, organs, tissues,
including the waste generated
from animals used in
experiments or testing in
veterinary hospitals or colleges
or animal houses.
(c) Soiled Waste:
Items contaminated with blood,
body fluids like dressings,
plaster casts, cotton swabs and
bags containing residual or
discarded blood and blood
components.

Incineration or Plasma
Pyrolysis or deep burial*
In absence of above facilities,
autoclaving or micro-waving/
hydroclaving
followed
by
shredding or mutilation or
combination of sterilization and
shredding. Treated waste to be
sent for energy recovery.

(d) Expired or Discarded

Medicines:
Pharmaceutical waste like
antibiotics, cytotoxic drugs
including all items
contaminated with cytotoxic
drugs along with glass or
plastic ampoules, vials etc.

Yellow colored
non-chlorinated
plastic bags or
containers

Expired `cytotoxic drugs and

items contaminated with
cytotoxic drugs to be returned
back to the manufacturer or
supplier for incineration at
temperature >1200 0C or to
common bio-medical waste
treatment facility (CBMWTF)
or hazardous waste treatment,
storage and disposal facility for
incineration at >12000C Or
Encapsulation or Plasma
Pyrolysis at>12000C.
All other discarded medicines
shall be either sent back to
manufacturer or disposed by
incineration.

(e) Chemical Waste:

Chemicals used in production
of biological and used or
discarded disinfectants.

Yellow colored
containers or
non-chlorinated
plastic bags

Disposed of by incineration or
Plasma Pyrolysis or
Encapsulation in hazardous
waste treatment, storage and
disposal facility.

(f) Chemical Liquid

Waste:

Separate
collection system

After resource recovery, the

chemical liquid waste shall be

Red

Liquid waste generated due to

use of chemicals in production
of biological and used or
discarded disinfectants, Silver
X-ray film developing liquid,
discarded Formalin, infected
secretions, aspirated body
fluids, liquid from laboratories
and floor washings, cleaning,
housekeeping and disinfecting
activities etc.

leading to
effluent treatment
system

pre-treated before mixing with

other wastewater. The
combined discharge shall
conform to the discharge norms
given in Schedule- III.

(g) Discarded linen,

mattresses, beddings
contaminated with blood or
body fluid.

Non-chlorinated
yellow plastic
bags or suitable
packing material

Non- chlorinated chemical

disinfection followed by
incineration or Plasma
Pyrolysis or for energy
recovery. In absence of above
facilities, shredding or
mutilation or combination of
sterilization and shredding.
Treated waste to be sent for
energy recovery or incineration
or Plasma Pyrolysis.

(h) Microbiology,
Biotechnology and other
clinical laboratory waste:
Blood bags, Laboratory
cultures, stocks or specimens of
microorganisms, live or
attenuated vaccines, human and
animal cell cultures used in
research, industrial laboratories,
production of biological,
residual toxins, dishes and
devices used for cultures.

Autoclave safe
plastic bags or
containers

Pre-treat to sterilize with nonchlorinated chemicals on-site as

per National AIDS Control
Organization or World Health
Organization guidelines
thereafter for incineration.

Contaminated Waste
(Recyclable)
(a) Wastes generated from
disposable items such as tubing,
bottles, intravenous tubes and
sets, catheters, urine bags,
syringes (without needles and
fixed needle syringes) and

Red coloured
non-chlorinated
Plastic bags or
containers

Autoclaving or micro-waving/
hydroclaving followed by
shredding or mutilation or
combination of sterilization and
shredding.
Treated waste to be sent to
registered or authorized
recyclers or for energy recovery

vacutainers with their needles

cut) and gloves.

or plastics to diesel or fuel oil

or for road making, whichever
is possible. Plastic waste should
not be sent to landfill sites.

White
(Translucent)

Waste sharps including

Metals:
Needles, syringes with fixed
needles, needles from needle tip
cutter or burner, scalpels,
blades, or any other
contaminated sharp object that
may cause puncture and cuts.
This includes both used,
discarded and contaminated
metal sharps

Puncture proof,
Leak proof,
tamper proof
containers

Autoclaving or Dry Heat

Sterilization followed by
shredding or mutilation or
encapsulation in metal
container or cement concrete;
combination of shredding cum
autoclaving; and sent for final
disposal to iron foundries
(having consent to operate from
the State Pollution Control
Boards or Pollution Control
Committees) or sanitary landfill
or designated concrete waste
sharp pit.

Blue

(a) Glassware:
Broken or discarded and
contaminated glass including
medicine vials and ampoules
except those contaminated with
cytotoxic wastes

Cardboard boxes
with blue colored
marking

Disinfection (by soaking the

washed glass waste after
cleaning with detergent and
Sodium Hypochlorite
treatment) or through
autoclaving or microwaving or
hydroclaving and then sent for
recycling.

b) Metallic Body Implants

Cardboard boxes
with blue colored
marking

Note:* Disposal by deep burial is permitted only in rural or remote areas

where there is no access to common biomedical waste treatment facility.
This will be carried out with prior approval from the prescribed authority
and as per the Standards specified in Schedule-III. The deep burial facility
shall be located as per the provisions and guidelines issued by Central
Pollution Control Board from time to time.
THE PROCESS FLOW OF BIOMEDICAL WASTE IN AIIMS HOSPITAL

GENERATION

SEGREGATION

PRE-TREATMENT
COLLECTION AND
INTRAMURALTRANSP
ORT
TEMPORARY
STORAGE

DISPOSAL

A. GENERATION
Waste is generated from different areas in the hospital. Major part of it is the general
waste from food, etc. However, most part of biomedical waste is produced in the
laboratories, OTs and inpatient wards during dressings and other procedures. Excluding
the general waste, the hospital and the centers on an average generate 2000 Kgs of
biomedical waste daily.
B. SEGRAGATION
This step is vital to a good biomedical waste management system. It may be defined as
the separation of various waste into the color coded bins/ plastic bags or other color
coded containers. The best course of action is to segregate the waste at the point of
generation itself by the generator.
C. PRE-TREATMENT

At AIIMS there are needle destroyers present in every area of patient care for destruction
of needles and syringes. These destroyed needles and syringes are then chemically treated
with 1% bleach solution before their final disposal in a translucent puncture proof, leak
proof and tamper proof container.
D. COLLECTION AND INTRA-MURALTRANSPORT
The biomedical waste generated in different areas of the hospital is collected by an
outsourced agency. The waste is collected on a daily basis (once/twice daily) depending
on the pre-planned collection schedule from various collection points agreed upon by the
agency. The collection in the morning hours is done by 8:00am and in the evening hours
before closure of the facility. No waste is allowed to be kept in the hospital for more than
24 hours. The waste is collected in the color coded bags, loaded on to the dedicated and
covered trolleys and transported to the temporary storage area.
E. TEMPORARY STORAGE
The biomedical waste collected from different areas are brought in to a common point
where they are stored temporarily till the next vehicle is loaded for final transportation.
The loaded vehicle leaves the hospital premises at three different times during the day to
the final treatment site.
F. FINAL DISPOSAL
The biomedical waste collected is finally disposed from the hospital in the loading
vehicles to the common biomedical waste treatment facility operated by the outsourced
vendor. There in, the waste is treated by incineration or autoclave as per guidelines at the
treatment facility.

STAFF SAFETY CONSIDERATIONS:

1. The staff handling the biomedical waste should ensure sufficient personal protection with
heavy duty gloves, masks, gumboots, rubber aprons and caps.
2. All workers involved in this work must be made aware of the hazardous nature of this
work.
3. All workers should be immunized against tetanus and Hepatitis B.

4. Persons suffering from any contagious or infectious disease should be restricted from
doing this hazardous work till deemed fit by competent physician.

CHAPTER 11
ANTIBIOTICS STEWARDSHIP POLICY

Antibiotics have been considered as miracle drugs saving enumerable lives from deadly
infections and enabling modern science to reap benefits of high impact discoveries such as organ
transplantation and cancer chemotherapy. Discovery of a number of antibiotics (penicillin,
chloramphenicol and streptomycin) in 1940s and 1950s, Time magazine run a story saying that
remedies are now in our backyard i. During this period, as there was significant improvement
in life expectancy as result of availability of antibiotics to treat infections, discovery of vaccines
and improved sanitation, young generation in America dreamed of disease free, death free life
i.

However, indiscriminate use of antibiotics has led to rapid emergence of antimicrobial resistance
(AMR) making practically all of these miracle drugs ineffective. With the pipeline of
development of new antibiotics being dry, and the AMR scaling at unprecedented levels, the
World today is on the verge of pre-antibiotics era. Jim ONeill, a famous British economist, in
a series on four reviews papers on AMR, estimated that the global burden of extra deaths due to
drug-resistant infections can be 10 million people every year by 2050, and it can result in loss of
economic output equivalent to current world economy ($100 trillion) ii.
In the face of crisis of AMR, improving the use of antibiotics in order to optimize use of
whatever is left is an important public health issue today. The accumulating evidence support that
that a hospital based program (Antibiotics stewardship policy; ASP) can help in judicious use of
antibiotics and thus improving beneficial outcomes and minimizing harmful effects such as
toxicity, AMR, iatrogeneses and the cost of care. Centre for Disease Control (CDC) has
recommended adoption of ASP in acute care settings iii.
ASP refers to a program that promotes judicious use of antibiotics. The ASP activities include
appropriate selection of antimicrobial agent with correct dose, route, duration and minimum
toxicity for treatment of bacterial infections.
The ASP requires being in place a formal program, dedicated teams and identified policies and
procedures (Figure 1)

multidisciplinary
team with
identified leader

AS
P
Polcies and
procedures

Resources: manpower,
financial, information
technology

Figure 1: Elements of Antibiotic Stewardship Policy (ASP)

Success of ASP requires implementation of a formal program with an identified leader preferably
a physician. The leader must be committed to the program and must hold accountability for its
outcome. The leader should ideally be full time for large institutions or at least allocates
sufficient time for its activities. There should be a multidisciplinary team consisting of a
microbiologist, a pharmacist, infectious disease specialist, hospital administrator, and
information technology (IT) expert. An IT expert can play a pivot role in ASP by leveraging on
IT potential for efficient data management and feedback. ASP team must work hand-in-hand
with hospital infection control (HIC) team. Coordinated activities of ASP and HIC teams can
produce significant improvement in patient safety, successful treatment of infections and
reducing cost.
The commitment of top leadership of institution is crucial for success of ASP. The institution
leadership must empower the ASP team and provide required resources.
MAIN COMPONENTS OF ASP
The following are main components of ASP. The team should be prudent to develop insight
about the prevalent circumstance in the hospital and prioritize interventions and introduce them
in a gradual manner.

1.INITIATE appropriately
a.

Identify RIGHT patient needing antibiotics. Do not give antibiotics without proper
indications (e.g. viral infections, non-infectious illness).

b.

Perform cultures before administering the first dose of antibiotics. The system should
enabled in such a way that there is a culture of taking specimen for culture before
antibiotics are initiated. Nurses should be empowered to take cultures if the physician had
forgotten to order for the same.

c.

Choose the antibiotic agent that is suited to the suspected pathogen. Make sure the
suspected pathogen is likely to be sensitive to empiric antibiotics based on sensitivity
pattern of the pathogen in previous reports in a given facility

d.

Avoid antibiotics that have overlapping spectrum (e.g. combination of quinolones and
cephalosporin)

e.

Whenever indicated, initiate antibiotics without any delay

f.

Specify the duration of therapy as per the indication

2.

ADMINISTER appropriately

a.

Use appropriate dose and frequency (consult standard formulary)

b.

Monitor the patient for toxicity of antibiotics and make appropriate amendment to
therapy (e.g. modifying doses and/or frequency if nephrotoxicity)

c.

Modify antibiotics therapy once the culture and sensitivity results are available

d.

Antibiotic therapy must be reviewed at all transitions and whenever there is a change in
patients condition and amend the therapy appropriately

3.

Give a TIME OUT to antibiotics at 48 hours of therapy

a.

Once culture reports are available, consider STOPPING OR DE-ESCALATING the

therapy based on culture and other investigation report and clinical course of the patient

4.

MAKE EXPERTISE pertaining to ASP at point of care

a.

Develop expertise in antibiotic use and make this available to end-user at the point of
care (e.g. guidelines for different disease conditions, making a drug formulary for
institutional use).

5.

MONITOR and share data

a.

Monitor and share data and provide feedback on antibiotic utilization, AMR, adverse
events, cost, and adherence to ASP practice

Mukherjee S. The Emperor of All Maladies: A Biography of Cancer. London: Fouth Estate, 2011.